IL Blue Review April 2021 - BCBSIL

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A newsletter for contracting institutional and professional providers

April 2021

Whatrsquos NewFree Vaccine Confidence and Process Improvement Webinars for ProvidersRegister today for our upcoming free Blue UniversitySM virtual events for providers What isVaccine Confidence and Implementation Science A Discussion on Vaccine ProcessImprovement All providers that are independently contracted with Blue Cross and Blue Shieldof Illinois (BCBSIL) are welcome to attend Read more on News and Updates

Visual Impairment on the Rise Why This MattersIn our annual Blue Review readership survey some readers asked for more articles onspecialty areas In response wersquove created a series of articles on vision impairment

Provider EducationBCCHPSM and MMAI Provider Alert 2020 Mandatory Annual Training Must BeCompleted by May 1 2021If you provide care and services to our Blue Cross Community Health PlansSM (BCCHP)andor Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members but you missedthe 2020 training deadline due to COVID 19 challenges take note Wersquove extended thedeadline to May 1 2021 ndash and you can complete your training by attending a webinar onApril 15

Provider Learning Opportunities

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BCBSIL offers free webinars and workshops for the independently contracted providers whowork with us A preview of upcoming training sessions is included in this monthrsquos issue

Clinical Updates Resources and RemindersWhen and How to Use Our Medical Policy Reference ListChecking eligibility and benefits confirms if prior authorization or pre-notification are requiredBut how do you know when to submit a voluntary predetermination request prior torendering services for our commercial non-HMO members Our Medical Policy ReferenceList can help

Reminder Hospital Administrative Days May Be Covered for Medicaid MembersBCBSIL will provide reimbursement for authorized inpatient stays extended beyond medicalnecessity also known as Administrative Days (ADs) for some BCCHP and MMAI members fordates of service on or after July 1 2019

Electronic OptionsSingle Online Access Point for EFT and ERA Enrollments Effective May 3 2021Starting May 3 2021 BCBSIL will offer a single access point for enrollment in ElectronicFunds Transfer (835 EFT) andor Electronic Remittance Advice (835 ERA) via the TransactionEnrollment tool on the Availityreg Provider Portal

Pharmacy ProgramSpecialty Pharmacy Update Changes to Select Medication List Effective June 12021Choosing a drug from our Select Medication List and billing for it with the appropriate NationalDrug Code (NDC) may result in a higher reimbursement rate than the rate applied for othernon-listed drugs in the same class

Read More

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Claims and CodingMedicaid Billing Reminders for Home and Community Based Services (HCBS)Waiver ProvidersThis article applies to HCBS providers ndash Illinois Department of Healthcare and Family Services(HFS) types 90 92 93 and 98 ndash who submit claims to BCBSIL for our BCCHP and MMAImembers

Focus on Behavioral HealthApplied Behavior Analysis May Be Covered for Some Medicaid Members withAutism Spectrum DisorderEffective Nov 1 2020 HFS began covering Applied Behavior Analysis (ABA) services forchildren age 0 through 20 years old and diagnosed with an autism spectrum disorder

Community InvolvementFree Programs for BCBSIL Members and Non-members at Blue DoorNeighborhood CenterSM

Encourage your patients to attend the free Mental Health Awareness and Womenrsquos HealthMonth events at our Blue Door Neighborhood Center (BDNCSM)

CMO PerspectiveNew Programs Aim to Reduce Disparities and Expand Care Access for ExpectantMothers and BabiesIn this monthrsquos CMO Perspective our Vice President and Chief Medical Officer Dr Derek JRobinson MD MBA FACEP CHCQM talks about new BCBSIL resources to help improvethe health outcomes of pregnant women and their infants in underserved communities acrossIllinois

Wellness and Member EducationHelp Close the Disparity Gap For Black Women and Breast CancerBreast cancer is one of the most common cancers among American women While breastcancer is most prevalent in white women Black women have a higher mortality rate

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Quality Improvement and ReportingBlood Pressure Control Speaking Out About the lsquoSilent KillerrsquoAre your patients aware that high blood pressure or hypertension is known as a silent killerbecause it usually has no warning signs

Notification and DisclosureImportant Dates and RemindersCheck here each month for a quick snapshot of recent implementations upcoming changesspecial events important deadlines and other reminders

Quick Reminders

Stay informedWatch the News and Updates on our Provider website for important announcements

Update Your InformationDo you need to update your location phone number email or other important details onfile with BCBSIL Use our online forms to request an information change

Provider TrainingFor dates times and online registration visit the Webinars and Workshops page

Contact UsQuestions Comments Send an email to our editorial staff

bcbsilcomBlue Cross and Blue Shield of Illinois a Division of Health Care Service Corporation a Mutual Legal Reserve Company anIndependent Licensee of the Blue Cross and Blue Shield Association300 E Randolph Street Chicago IL 60601copy Copyright 2021 Health Care Service Corporation All Rights ReservedLegal and Privacy | Unsubscribe

April 2021

Visual Impairment on the Rise Why This Matters

In our annual Blue Review readership survey some readers asked for more articles on specialty areas In response wersquovecreated a series of articles on vision impairment Do you have suggestions for other topics Email us

According to the Centers for Disease Control and Prevention (CDC) more than 34 million Americans aged 40 years andolder are blind or visually impaired and a total of 80 million Americans have potentially blinding eye diseases The major

causes of vision loss are cataracts age-related macular degeneration diabetic retinopathy and glaucoma1 PreventBlindness America projects these populations will grow substantially in the future by 2032 it is estimated that the visuallyimpaired population aged 40 and older will increase by 66 to nearly 51 million and the blind population will increase 59

to 22 million2

People with vision loss are more likely to experience depression diabetes hearing impairment stroke falls cognitivedecline and premature death Decreased ability to see often leads to the inability to drive read keep accounts and travelin unfamiliar places thus substantially compromising quality of life The economic cost of vision loss in the US including

direct costs and lost productivity is estimated to exceed $35 billion3

How You Can HelpIf yoursquore an eye care specialist share results with your patientrsquos primary care physician (PCP) to help coordinate careIf yoursquore a PCP remind your diabetic patients to get an annual eye exam as recommended by the American Diabetes

Association (ADA)4

Make sure Hadley is on your resource list

Whorsquos HadleyHadley a 100-year-old learning destination for those facing vision loss offers short workshops covering everyday activitieslike using a smart phone marking medications or kitchen safety Experts from the field of vision loss staff all workshopsand readily address personalized questions whether received online on the phone or in the mail As a privately fundednonprofit Hadley provides workshops completely free of charge For more information about Hadley visit their websitecall 800-323-4238 or email them


Other Resources for Our MembersIn addition to vision benefits that vary by plan Blue Cross and Blue Shield of Illinois (BCBSIL) offers members discounts

on laser eye surgery eye exams contacts and frames through Blue365reg No referral is necessary and therersquos no limit tothe number of times members can receive discounts on purchases

BCBSIL is also working with Esperanza Health Centers and five other clinics in the Chicago area to help improvescreening rates for diabetic retinopathy The clinics offer free diabetic retinopathy screenings to BCBSIL members andnon-members

1 CDC Vision Loss A Public Health Problem June 12 2020 httpswwwcdcgovvisionhealthbasic_informationvision_losshtm

2 Prevent Blindness America The Future of Vision June 2014 httpspreventblindnessorgwp-contentuploads202004Future_of_Vision_final_0pdf

3 Rein DB Zhang P Wirth KE et al The economic burden of major adult visual disorders in the United States ArchOphthalmol 2006124(12)1754ndash1760

4 ADA Focus on diabetes Look closer at eye health 2021 httpseyehealthdiabetesorg

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider Physicians and other healthcare providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment Thefact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage formore details including benefits limitations and exclusions Regardless of benefits the final decision about any service or treatment is between the member and their health care provider

Blue365 is a discount-only program for BCBSIL members Discounts are only given through vendors that take part in this program BCBSIL does not guarantee or make any claims orrecommendations about the programrsquos services or products Members are advised to consult their doctor before using these services and products Some of the services offered through thisprogram may be covered under some membersrsquo health benefit plans Members should check their benefit booklet or call the Customer Service number on their BCBSIL ID card for specificbenefit facts

bcbsilcomproviderBlue Cross and Blue Shield of Illinois a Division of Health Care Service Corporation a Mutual Legal Reserve Company an Independent Licensee of the Blue Cross and Blue ShieldAssociation

copy Copyright 2021 Health Care Service Corporation All Rights Reserved

April 2021

BCCHPSM and MMAI Provider Alert 2020 Mandatory Annual Training Must Be Completed byMay 1 2021

This reminder applies to all providers that are independently contracted with Blue Cross and Blue Shield of Illinois(BCBSIL) to provide care and services to the following government programs members Blue Cross Community Health

PlansSM (BCCHP) andor Blue Cross Community MMAI (Medicare-Medicaid Plan)SM

The Centers for Medicare amp Medicaid Services (CMS) and Illinois Department of Healthcare and Family Services (HFS)require that BCBSIL makes available provider training on specific topics related to our government programs membersBCCHP and MMAI contracted providers have until the end of each calendar year to comply with required annualcultural competency training

As we reminded you in our September 2020 Blue Review the deadline for completion of mandatory training last year wasDec 31 2020 We understand that due to challenges related to the COVID-19 pandemic some providers wereunable to meet the 2020 deadline For the 2020 mandatory training BCBSIL is granting an extension to non-compliant providers requiring that they complete the annual training modules by May 1 2021

Failing to complete the annual compliance training is a breach of your provider participation agreement withBCBSIL which may result in a notice of termination of the agreement

You have three options to complete the required training1 Complete the training modules located on our Provider Training RequirementsResources page2 Complete an attestation for your facility group andor individual providers Attestation submissions should include a

listing of all trained providersstaff with their affiliated tax ID numbers (TINs) to ensure credits are applied appropriately3 Join us for a webinar training session See below to register

Join Us for a BCCHP and MMAI Required Provider Training Webinar on April 15 2021Our guided webinar will review all the required provider trainings and allow you to complete an attestation for yourfacility group andor individual providers Register now for the webinar on April 15 2021 ndash 9 to 11 am


For more information refer to the Provider Training RequirementsResources page If you have any questions contactyour Provider Network Consultant or email our Government Programs Provider Relations team



April 2021


Blue Cross and Blue Shield of Illinois (BCBSIL) offers free workshops and webinars for the independently contractedproviders who work with us These trainings focus on electronic options and other helpful tools and resources A previewof upcoming training sessions is included below For more information refer to our Webinars and Workshops page

BCBSIL WEBINARSTo register now for a webinar on the list below click on your preferred session date

Descriptions Dates Session Times

Availityreg Authorizations ToolWe are hosting one-hour webinar sessions for providers to learnhow to electronically submit inpatient and outpatient benefitpreauthorization requests handled by BCBSIL using AvailityrsquosAuthorizations tool

April 14 2021April 21 2021April 28 2021

11 am to noon

Availity Claim Status We are hosting complimentary webinars for providers to learn howto verify detailed claim status online using Availityrsquos Claim Statustool

April 8 2021April 15 2021April 22 2021April 29 2021

11 to 1130 am

Availity Remittance Viewer and Reporting On-DemandThese online tools give providers and billing services a convenientway to view claim detail information from the 835 ElectronicRemittance Advice (835 ERA) and the Provider Claim Summary(PCS) Attend a webinar to learn how to gain or grant accessconduct a search view general and payer-specific information andsave or print results

April 15 2021 1 to 2 pm


BCBSIL Back to Basics lsquoAvaility 101rsquoJoin us for a review of electronic transactions provider tools andhelpful online resources


11 am to noon

BCCHPSM and MMAI Required Provider Training Webinars If you provide care and services to our Blue Cross Community

MMAI (Medicare-Medicaid Plan)SM andor Blue Cross Community

Health PlansSM (BCCHP) members please join us for guidedwebinars that will review all the provider trainings required by theCenters for Medicare amp Medicaid Service (CMS) andor IllinoisDepartment of Healthcare and Family Services (HFS)

April 15 2021 1 to 3 pm

Medicaid HEDISreg 102 TrainingThis training is designed for contracted providers working with newBCCHP and MMAI members Wersquoll review HealthcareEffectiveness Data and Information Set (HEDIS) measure updatesdiscuss strategies to sharpen your knowledge of HEDIS measuresand cover the measure year (MY) 2020 and MY 2021 HEDIStechnical specifications and general guidelines

April 8 2021April 14 2021

Noon to 1 pm

Monthly Provider Hot Topics WebinarThese monthly webinars will be held through December 2020They are customized for the BCBSIL contracted providercommunity BCBSIL Provider Network Consultants (PNCs) will usethis format to share upcoming initiatives program changes andupdates as well as general network announcements

April 14 2021 10 to 11 am

Orientation Webinars for New BCCHP ProvidersThese orientation webinars will give you the opportunity to ask thePNCs questions and will highlight topics such as care coordinationthird party vendors claims prior authorization and requiredprovider training

April 20 2021 10 to 1130 am

Orientation Webinars for New Commercial ProvidersThese orientation webinars will give you the opportunity to ask thePNCs questions and will highlight topics such as networkparticipation and benefits claims post-processing claim inquiriessupplemental resources credentialing and contracting

April 21 2021 10 to 1130 am

Single Access Point for 835 EFT and ERA EnrollmentsWe are hosting complimentary webinars for providers to learn howto enroll online via Availity

April 19 2021April 21 2021April 23 2021April 27 2021April 29 2021

1 to 2 pm10 to 11 am2 to 3 pm9 to 10 am3 to 4 pm

Blue UniversitySM

To register now for a webinar hosted by Dr Suzanne R White MD MBA FACEP FACMT aRegional Medical Director employed by Merck amp Co on the list below click on your preferredsession date


What is Vaccine ConfidenceDiscussion will include possible strategies to communicateeffectively about vaccines and several possible solutions tobuilding vaccine confidence

April 8 2021 1 to 2 pm

Implemental Science A Discussion on Vaccine ProcessImprovementDiscussion will include case studies and various organizationaltools that can be used to address barriers and promotesustainability of change

April 13 2021 10 to 11 am

Availity is a trademark of Availity LLC a separate company that operates a health information network to provide electronic information exchange services to medical professionals Availityprovides administrative services to BCBSIL BCBSIL makes no endorsement representations or warranties regarding any products or services provided by third party vendors such asAvaility If you have any questions about the products or services provided by such vendors you should contact the vendor(s) directly



April 2021

When and How to Use Our Medical Policy Reference List

Itrsquos important to check eligibility and benefits first before providing care and services This step helps you determine if priorauthorization or pre-notification may be required for our non-HMO members Donrsquot forget though for commercial non-HMO members even if prior authorization and pre-notification arenrsquot required you may want to submit a voluntarypredetermination request See the Utilization Management Process Overview (Commercial) for a high-level decision treeThis overview is located in the Utilization Management section of our Provider website

The Utilization Management section also includes other resources to help you decide when to submit predeterminationrequests Our Medical Policy Reference List is located in the Related Resources on the Predetermination page

This list shows procedure codes for services that are subject to medical necessity review based on our medicalpoliciesTo help avoid post-service review for these codesprocedures submit a voluntary predetermination request prior torendering servicesQuick tip To go right to a specific code or description on the Medical Policy Reference List press the ldquoCTRLrdquo and ldquoFrdquokeys at the same time ndash this will open a search field

Remember you can submit predetermination requests electronically using the Attachments Tool on the Availityreg ProviderPortal See the user guide for details

The Medical Policy Reference List is not an exhaustive list of all codes Codes may change and this list may be updated throughout the year The presence of codes on this list does notnecessarily indicate coverage under the member benefits contract Member contracts differ in their benefits Consult the member benefit booklet or contact a customer service representativeto determine coverage for a specific medical service or supply

Checking eligibility andor benefit information andor obtaining prior authorization pre-notification or predetermination is not a guarantee of payment Benefits will be determined once a claimis received and will be based upon among other things the memberrsquos eligibility and the terms of the memberrsquos certificate of coverage including but not limited to exclusions and limitationsapplicable on the date services were rendered If you have any questions contact the number on the memberrsquos ID card





April 2021

Reminder Hospital Administrative Days May Be Covered for Medicaid Members

Blue Cross and Blue Shield of Illinois (BCBSIL) may provide reimbursement for authorized inpatient stays extended

beyond medical necessity also known as Administrative Days (ADs) for some Blue Cross Community Health PlansSM

(BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members for dates of service on or after July1 2019

ADs are inpatient stay days for members who no longer require acute hospital care but discharge to a sub-acute or post-

acute setting has proven problematic due to the unique circumstances of these members1

Itrsquos expected that providers will consider any unique circumstances early in each memberrsquos stay and will begin workingcollaboratively with BCBSIL Utilization Management and Care Management Coordinators on discharge planning as soonas potential barriers are identified Itrsquos the responsibility of the facility to ensure reasonable efforts are made to engageBCBSIL in discharge planning and to ensure barriers to discharge are documented in advance of the discharge date Ifyou have a BCCHP or MMAI member that meets the AD description above a prior authorization request specifically forthe ADs is required through BCBSIL within one business day from the members transition in level of care

Always check eligibility and benefits through the Availityreg Provider Portal or your preferred web vendor prior to renderingcare and services to BCBSIL members This step will confirm membership status coverage details and prior authorizationrequirements

How to request prior authorization for ADs Prior authorization requests may be made by phone (call 877-860-2837 forBCCHP members call 877-723-7702 for MMAI) or by fax to 312-233-4060 (same fax number for BCCHP and MMAImembers) Prior authorization requests for ADs may not be submitted online at this time

Prior authorization through BCBSIL is required for all planned inpatient care The following information should accompanythe prior authorization request

Documented discharge plan in place to a lower level of careDocumented attempts to place the memberDocumented barriers to implementation of the discharge plan which are beyond the control of the provider


Exclusionary Criteria A member will not qualify for ADs if any of the below points apply Please review these criteriabefore submitting an AD prior authorization request

The member has met their discharge criteria and barriers to discharge no longer existThe inpatient facility is pursuing a discharge to a level of care or service that BCBSIL has stated is not a coveredbenefit for the memberThe facility has not worked with BCBSIL to identify alternative and appropriate placementsLong Term Acute Care Hospitals (LTACHs) are not eligible for ADs reimbursementBCBSIL is not responsible for ADs that are the responsibility of the Illinois Department of Children and Family Services(DCFS)

Reimbursement rates are defined by the Illinois Department of Healthcare and Family Services (HFS) Medicaid HighVolume Adjustments (MHVA) Medicaid Percentage Adjustment (MPA) or any other add-on payments do not apply toADs Information regarding prior authorization claims and reimbursement may be obtained through the facilityrsquos ProviderNetworking Coordinator

For more information review the IAMHP Administrative Days memo

1 IAMHP Administrative Days Reimbursement Implementation 2019 httpsiamhpnetresourcesDocumentsAD20Days20Implementation2020FINAL201-22-2120pdf

The material presented here is for informationaleducational purposes only is not intended to be medical advice or a definitive source for coding claims and is not a substitute for theindependent medical judgment of a physician or other health care provider Health care providers are encouraged to exercise their own independent medical judgment based upon theirevaluation of their patientsrsquo conditions and all available information and to submit claims using the most appropriate code(s) based upon the medical record documentation and codingguidelines and reference materials References to other third-party sources or organizations are not a representation warranty or endorsement of such organization Any questions regardingthose organizations should be addressed to them directly The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefitand members should refer to their certificate of coverage for more details including benefits limitations and exclusions Regardless of benefits the final decision about any service ortreatment is between the member and their health care provider

Checking eligibility andor benefit information andor the fact that a service has been prior authorized is not a guarantee of payment Benefits will be determined once a claim is received andwill be based upon among other things the memberrsquos eligibility and the terms of the memberrsquos certificate of coverage applicable on the date services were rendered If you have questionscall the number on the memberrsquos ID card




April 2021

Single Online Access Point for EFT and ERA Enrollments Effective May 3 2021

Starting May 3 2021 Blue Cross and Blue Shield of Illinois (BCBSIL) will offer a single access point for enrollment inElectronic Funds Transfer (835 EFT) andor Electronic Remittance Advice (835 ERA) via the Transaction Enrollment tool

on the Availityreg Provider Portal As of this date faxed or mailed EFT or ERA enrollment applications includingchangecancel requests will be returned and redirected to the electronic option

Enrollment in electronic options remains an opt-in arrangement If you currently receive paper checks andor paperprovider claim summaries you may continue to do so However enrolling for EFT and ERA can help increaseadministrative efficiencies within your provider organization Electronic transactions offer more convenience and greatersecurity of patient and provider information Refer to the Claim Payment and Remittance page for more information

Education and TrainingItrsquos easy to enroll online for EFT and ERA via Availity See our EFT and ERA Enrollment User Guide for instructions Orjoin us for a free webinar and wersquoll walk you through the process To register for a training session select your preferreddate and time below

April 19 2021 ndash 2 to 3 pmApril 21 2021 ndash 10 to 11 amApril 23 2021 ndash 11 to noonApril 27 2021 ndash 1 to 2 pmApril 29 2021 ndash 3 to 4 pm

If these dates and times arenrsquot convenient for your office email Electronic Commerce Services for other training options

Already enrolled for 835 EFT and ERA delivery from BCBSILYou donrsquot need to enroll againAvailityrsquos Transaction Enrollment tool should also be used to change andor cancel your existing EFT or ERA delivery

Note If you have questions or if you believe your provider organization should be exempt from the online enrollmentprocess email our Electronic Commerce Services team





April 2021

Specialty Pharmacy Update Changes to Select Medication List Effective June 1 2021

National Drug Codes (NDCs) and NDC data are required by Blue Cross and Blue Shield of Illinois (BCBSIL) for drugsbilled under the medical benefit on professionalancillary electronic (ANSI 837P) and paper (CMS-1500) claims When youbill with NDCs BCBSIL can identify and reimburse you for the individual medication that was prescribed (instead of for arange of NDCs within the applicable procedure codes)

With this capability in mind BCBSILrsquos Select Medication List includes specific drugs within particular classes or categoriesbased on safety and cost effectiveness Choosing a drug from the Select Medication List and billing for it with theappropriate NDC may result in a higher reimbursement rate than the rate applied for other non-listed drugs in the sameclass

The Select Medication List is posted in the Specialty Pharmacy section under the Related Resources Currently itincludes two injections from the viscosupplementation class that are used primarily for osteoarthritis knee pain reliefUpcoming changes are noted below

The products on the Select Medication List will be updated effective June 1 2021

Euflexxareg will be removed as a viscosupplement from the Select Medication List It will be replaced by Orthoviscreg

Synvisc-Onereg will remain on the Select Medication List Please note reimbursement may change to reflect these productchanges

The listing of any particular drug or classification of drugs is not a guarantee of benefits Payment of benefits is subject to several factors including but not limited to eligibility at the time ofservice terms conditions limitations and exclusions set forth in the memberrsquos policy or benefits document Members should refer to their contract of coverage for more details includingbenefits limitations and exclusions Regardless of benefits the final decision about any medication is between the member and their health care provider

Euflexxa is a registered trademark of Ferring BV Orthovisc is a registered trademark of DePuy Synthes Synvisc-One is a registered trademark of Genzyme Corporation




April 2021

Medicaid Billing Reminders for Home and Community Based Services (HCBS) WaiverProviders

This article applies to HCBS providers ndash Illinois Department of Healthcare and Family Services (HFS) types 90 9293 and 98 ndash who submit claims to Blue Cross and Blue Shield of Illinois (BCBSIL) for our Blue Cross CommunityHealth PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members

BCBSIL has aligned its claim coding with HFS managed care billing and guidelines for HCBS waiver providers regardingMedicaid claims for Managed Care Organizations (MCOs) HCBS providers should also refer to the Illinois Association ofMedicaid Health Plans (IAMHP) Comprehensive Billing Manual available on the IAMHP website

When billing HCBS services HCBS provider types should only use their HFS Legacy Provider Numbers (Medicaid IDs) ndashthey should not use their National Provider Identifiers (NPIs) on Medicaid claims On BCCHP and MMAI member claimsthe HFS Legacy Provider Number (Medicaid ID) must match the Illinois Medicaid Program Advanced Cloud Technology(IMPACT) Legacy Provider Number (Medicaid ID) BCBSIL wonrsquot be able to process the claim if the HFS Legacy ProviderNumber (Medicaid ID) used doesnrsquot match the corresponding IMPACT Legacy Provider Number (Medicaid ID) andIMPACT-registered categories of service specialties etc The providerrsquos HFS Legacy Provider Number (Medicaid ID)must match the IMPACT-registered provider type that corresponds with the memberrsquos waiver type

Illinois Medicaid HCBS Billing Waiver ndash Electronic Claim Submission Atypical providers rendering HCBS for our BCCHP and MMAI members may submit electronic professional claims (837P

transactions) to BCBSIL These claims may be submitted through your practice management system the Availityreg

Provider Portal or another preferred web vendor using Payer ID MCDIL

To accurately submit these claims to BCBSIL using Availityrsquos Electronic Professional Claim Submission tool a validLegacy Provider Number (Medicaid ID) is required in the Payer Assigned ID field (2010BB-REFG2) For the PayerAssigned ID field to appear on the Availity 837P submission your Availity Administrator must first add your information toenable Availityrsquos Express Entry function as follows

How to Set-up Availityrsquos Express Entry (Instructions for Availity Administrators)1 Log in to Availity


2 Select ldquoMy Providersrdquo from the navigation menu3 Select ldquoExpress Entryrdquo4 Select ldquoAdd Providerrdquo and click the link for ldquoThis provider is not required to have an NPIrdquo5 Enter the Atypical Provider Information including the Tax ID number6 Select ldquoSave Providerrdquo

After the Express Entry set-up is completed you may use the ldquoSelect a Providerrdquo drop-down listing in the Billing ProviderInformation section on the Availity 837P submission tool Your associated provider data will populate and the PayerAssigned ID field will appear to enter the 12-character Medicaid ID

If you need training or help with electronic claim submission email our Provider Education Consultants

What to Do if You Have Multiple Registrations with HFS If you have multiple registrations with HFS for provider types outside of the HCBS service realm only include your NPI onclaims for non-HCBS services For example if yoursquore registered as an HFS Home Health provider type (050) and alsoregistered as an HCBS provider (090) and yoursquore billing for Home Health services you must submit an electronicinstitutional provider claim (837I transaction) using your NPI in the 2010AA Billing Loop When billing as HCBS with HFSprovider type 090 you must submit an electronic professional claim (837P) using your Medicaid ID without an NPI Referto the Home Health Care section of the Comprehensive Billing Manual on the IAMHP website for billing rules to MCOs

Personal Assistants and Individual Providers BCBSIL works with our members to develop individualized care plans that may include personal assistants We willprovide care coordination and oversight of the services being provided to our BCCHP and MMAI members Personal

Assistants (PAs) and Individual Providers (IPs) that are not working through an agency are required to enroll in IMPACTWhen seeking reimbursement PAs and IPs may not submit claims directly to the MCOs They are required to log theirtime using the electronic visit verification system so that payment can be issued by the State of Illinois

Electronic Data Interchange (EDI) ndash Claim Rejection Update HCBS providers should take note of a new EDI claim rejection thatrsquos based on validating the presence of the providerrsquosHFS Medicaid ID on the claim If the HFS Medicaid ID is missing this is the rejection that will be returned in the 277CAClaims Acknowledgement

STC Segment Data Value

STC01-01 A3

STC01-02 562

STC01-03 85

STC12 Waiver claims should not be submitted with an NPI

For more information refer to the appropriate Provider Manual If you have questions email your Provider NetworkConsultant (PNC) or call 855-653-8126




April 2021

Applied Behavior Analysis May Be Covered for Some Medicaid Members with AutismSpectrum Disorder

Effective Nov 1 2020 the Illinois Department of Healthcare and Family Services (HFS) began covering Applied BehaviorAnalysis (ABA) services for children age 0 through 20 years old and diagnosed with an autism spectrum disorder Blue

Cross and Blue Shield of Illinois (BCBSIL) aligned with HFS for Blue Cross Community Health PlansSM (BCCHPSM) claimsto administer this benefit

According to HFS ABA is the design implementation and evaluation of environmental modifications using behavioralstimuli and consequences to produce socially significant improvement in human behavior including the use of direct

observation measurement and functional analysis of the relationships between environment and behavior1

Per Public Act 101-10 treatment of autism spectrum disorder through applied behavior analysis shall be covered underthe medical assistance program for children with a diagnosis of autism spectrum disorder when ordered by a physicianlicensed to practice medicine in all its branches and rendered by a licensed or certified health care professional withexpertise in applied behavior analysis

If you provide ABA services to Medicaid members you must be registered in the HFS Illinois Medicaid Program AdvancedCloud Technology (IMPACT) system with the specialty or sub-specialty listed below

Clinical Psychologist (Provider Type 87) ndash These providers MUST have a Board Certified Behavioral Analyst(BCBA) sub-specialty (Category of Service 118) in IMPACTLicensed Clinical Social Worker (Provider Type 86) ndash These providers MUST have a BCBA sub-specialty(Category of Service 118) in IMPACTRegistered Behavior Technician (Provider Type 88) ndash These providers MUST have a Registered BehaviorTechnician specialty (Category of Service 119) in IMPACT

We expect our systems to be ready to process and pay claims for ABA soon Claims may reject or deny in theinterim

Reminders and Related ResourcesAs noted in our Medicaid Prior Authorization Requirements Summary prior authorization through BCBSIL is required for


ABA services The BCBSIL prior authorization process may vary from HFS Always check eligibility and benefits through

the Availityreg Provider Portal or your preferred web vendor prior to rendering care and services to BCBSIL members Thisstep will confirm membership status coverage details and prior authorization requirements A Medicaid Prior AuthorizationProcedure Code List is posted for reference purposes

To request prior authorization of ABA services for BCCHP members you may use the Availity Authorizations tool Alsocomplete and submit the following required forms to BCBSIL according to the instructions on each form

Applied Behavioral Analysis ndash Clinical Service Request FormApplied Behavioral Analysis ndash Initial Assessment Request Form


1 HFS Provider Notice Issued Oct 30 2020 httpswwwillinoisgovhfsMedicalProvidersnoticesPagesprn201030caspx





April 2021

Free Programs for BCBSIL Member and Non-members at Blue Door Neighborhood CenterSM

Encourage your patients to attend the free Mental Health Awareness and Womenrsquos Health Month events at our Blue

Door Neighborhood Center (BDNCSM) Since programming is virtual due to COVID-19 all your patients can takeadvantage of these activities no matter where they live

In May in addition to our popular yoga Zumba and meditation classes the BDNC will offer opportunities for women tolearn best practices and tips to help stay healthy physically and mentally Courses may include lessons on maintaininga healthy weight getting and staying active eating a heart-healthy diet managing stress and sleep habits

In addition community members attending the Ask A Doctor events can virtually ask questions about mentalbehavioralhealth and womenrsquos health topics that are of concern to them

These are just a few of the programs wersquoll offer at BDNC on multiple dates and times during Mental Health Awareness andWomenrsquos Health Month Encourage your patients to check the calendars at BDNC at Morgan Park BDNC at Pullman andBDNC at South Lawndale for details and to register They can also visit the BDNC Facebook page for other events andhappenings at all three locations

Supporting our members on their health education journeys and increasing access to health care where our members livework and play is an ongoing priority at BCBSIL Wersquore also committed to help strengthen the health of communities acrossthe state BDNC gives BCBSIL the opportunity to partner with you the provider community to help make a difference inthe lives of residents in our communities Once we open our doors to in-person guests please encourage your patients tostop by If you or your patients have questions email the BDNC or call 773-253-0900

Wersquod love to hear from you Would you like more information about BDNC Are there coursesactivities yoursquod like to seeoffered at BDNC Will you encourage your patients to visit BDNC Would you like to get more involved at BDNC Takeour short survey and let us know what you think

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider Physicians and other healthcare providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatmentReferences to third party sources or organizations are not a representation warranty or endorsement of such organizations Any questions regarding those organizations should be addressedto them directly The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to theircertificate of coverage for more details including benefits limitations and exclusions Regardless of benefits the final decision about any service or treatment is between the member and their


health care provider



April 2021

New Programs Aim to Reduce Disparities and Expand Care Access for Expectant Mothersand Babies

By Dr Derek J Robinson MD MBA FACEP CHCQM Vice President and Chief Medical Officer Blue Cross andBlue Shield of Illinois (BCBSIL)

The US has the highest maternal and infant mortality rates in comparison to other developed countries1 and the

statistics2 are worse for women of color While these racial disparities persist across economic and education boundariesfor pregnant and post-partum women those living in low-income and remote communities face unique challenges IllinoisDepartment of Public Health data shows that non-Hispanic Black women are six times as likely to die of a pregnancy-

related condition as non-Hispanic white women3

As part of our effort to achieve health equity BCBSIL is providing new resources to help improve the health outcomes ofpregnant women and their infants in underserved communities across Illinois This maternal health initiative is one of theways BCBSIL is reinvesting payments from the Illinois Department of Healthcare and Family Services (HFS) for providingquality care to Medicaid members

Community-based InterventionsBCBSIL has announced more than $350000 in grant funding to six community-based organizations working to improvematernal health outcomes on Chicagorsquos South and West Side neighborhoods Herersquos a summary of grantees andprograms being created or expanded

Catholic Charities ndash Funding for the Altgeld Gardens Adolescent Parenting Support program will support a pregnancyand early childhood (age 5+) home visiting program to increase access to health care and address social determinantsof health (SDOH) for young mothers ages 14-25 The program also sends doulas to homes from the 3rd trimesterthrough 8 weeks postpartumChicago Volunteer Doulas ndash The Doulas for Health Equity program will use the funding to support its birth doulasprogram on-call doula program postpartum doulas support and doula training at the Logan Correctional CenterEverThrive Illinois ndash The Chicago Collaborative for Maternal Health led by AllianceChicago and EverThrive ILimplements a community maternal health intervention that brings together health care and community social serviceproviders women and their families and policymakers to help address maternal mortality prevention in Chicago Grant


funds will be used for family education on maternal morbidity and prevention through canvassing interactivepresentations and train the trainer seminarsMelanated Midwives ndash The Maternal Health Project will use funding to support educational video medicine visits toprenatal and postpartum support during COVID-19Peaceful Birth Practices ndash Sisters Circle Too is a 6-week community-based trainingmentorship program for women ofcolor specializing in promoting leadership in the field of maternal-child health BCBSIL funding will help educateproviders on the importance of doulas and allowing them access within hospitalsWomenrsquos Care Consulting LLC ndash The Enhancing Access to Womens Health Care through Telemedicine program willimprove availability of telehealth and counseling in early pregnancy and postpartum

Holistic Group CareBCBSIL is teaming up with the Centering Healthcare Institute (CHI) a non-profit focused on delivering better healthoutcomes and improving the care experience for patients and their doctors Through a three-year grant BCBSIL will be

bringing CHIrsquos CenteringPregnancyreg program to a number of Federally Qualified Health Centers (FQHCs) that focus onserving underserved and at-risk populations CenteringPregnancy is a nationally recognized model of group prenatal carepromoting education and social support by bringing together women in the same stage of pregnancy Family ChristianHealth Center is the first FQHC to begin implementing CenteringPregnancy as part of BCBSILrsquos program expansion Itaims to launch the program this summer after opening its Maternal Child Health and Wellness location in Harvey in mid-April

Early InterventionsSome programs build on other assistance from BCBSIL to help improve maternal and newborn health At our Blue Door

Neighborhood CenterSM sites we recently hosted a three-week virtual Pregnancy Program with SIDS of Illinois and avirtual ldquoCommunity Baby Showerrdquo featuring interactive games giveaways and healthy pregnancy and healthy babyeducation and resources from a variety of partner organizations Both programs are being planned again for April 2021Additional Community Baby Showers are in development for Springfield Peoria and Winnebago County

We also offer special programs for our members depending on their benefit plan Special Beginningsreg provides personalattention and information new mothers may need to care for themselves and their babies during pregnancy and up to sixweeks after giving birth Highlights include

A healthy pregnancy calendarVideos that cover topics such as eating habits exercise stress and moreDetails about each trimester and the physical and emotional changes in mom and babyA list of screenings and vaccines to help prepare for checkupsProgram support Monday through Friday from 8 am to 630 pm CT

Finally our Womenrsquos and Family Health program provides access to fertility pregnancy and parenting resourcesincluding

Ovia HealthTM apps provide members with real-time personalized support via in-app coaching articles videos tipstracking tools and more The apps include Ovia Fertility Ovia Pregnancy and Ovia Parenting ndash all of which areintegrated with our internal programs helping to identify and support high-risk pregnancies and complicated birthsHigh-risk maternity management provides telephone outreach and ongoing support to expectant mothers identified withhigh-risk pregnancies

Well onTargetreg has self-guided courses about pregnancy that members can take online covering topics such ashealthy foods body changes and labor

In closing BCBSIL continues to explore ways to collaborate with health care teams in improving maternal and infanthealth In our value-based care programs wersquore supporting efforts to help reduce disparities in severe maternal morbidity

by focusing reporting and incentives on the use of best practices in addressing maternal hypertension and hemorrhageDr Anita Stewart a BCBSIL medical director for Illinois Medicaid initiatives has championed efforts to end early electivedeliveries and is working with hospitals and health systems on quality improvement efforts to reduce avoidable C-sectionsIt will take a village to improve the health of moms and babies We welcome your ideas and the opportunity to sharesuccess stories

Learn more about Dr Derek J Robinson

1 The Commonwealth Fund Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries Nov 18 2020httpswwwcommonwealthfundorgpublicationsissue-briefs2020novmaternal-mortality-maternity-care-us-compared-10-countries

2 Centers for Disease Control and Prevention Maternal Mortality Nov 9 2020 httpswwwcdcgovnchsmaternal-mortalityindexhtmCDC_AA_refVal=https3A2F2Fwwwcdcgov2Fnchs2Ffastats2Fmaternal-mortalityhtm

3 Illinois Depatment of Public Health Illinois Maternal Morbidity and Mortality Report October 2018httpdphillinoisgovsitesdefaultfilespublicationspublicationsowhmaternalmorbiditymortalityreport112018pdf

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider Physicians and other healthcare providers are encouraged to use their own medic judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment Thefact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage formore details including benefits limitations and exclusions Regardless of benefits the final decision about any service or treatment is between the member and their health care provider

Well onTarget is a registered mark of Health Care Service Corporation a Mutual Legal Reserve Company

CenteringPregnancy is a trademark of Centering Healthcare Institute Ovia Health is an independent company that has contracted with BCBSIL to provide maternity and family benefitssolutions for members with coverage through BCBSIL BCBSIL makes no endorsement representations or warranties regarding third party vendors and the products and services offered bythem



April 2021

Help Close the Disparity Gap for Black Women and Breast Cancer

Breast cancer is one of the most common cancers among American women While breast cancer is most prevalent inwhite women Black women have a higher mortality rate Not only do Black women have the highest breast cancermortality rate of all races and ethnicities but they have a 40 higher breast cancer mortality rate compared to white

women1

Black women are more likely to have denser breasts (an indicator of breast cancer risk) and to develop breast cancerbefore age 50 Black women are at an increased risk for triple negative breast cancers which are typically associated with

poorer health outcomes and they have a shorter survival rate 5 years after diagnosis2

Black women are also more likely to be at an advanced stage at diagnosis largely due to lower access to quality care andpotentially receiving health care services at lower resourced or unaccredited facilities inadequate mammogram

screenings and lack of timely follow-up for abnormal findings1 Due to these disparities early breast cancer screening iseven more critical for Black women

How You Can HelpOutreach and educate our members on the importance of breast cancer screening and discuss the unique risks thatimpact Black women Optimize use of telehealth services when available and appropriate for preventive care appointmentsEncourage members to complete the Assess Your Risk quiz offered by Bright Pink to learn more about their personalbreast and ovarian cancer riskParticipate in shared decision making to identify the best screening and treatment options for each memberAssist members in scheduling mammogram appointments and help ensure access to transportation Blue Cross andBlue Shield of Illinois (BCBSIL) provides Medicaid members with free non-emergency transportation servicesPartner with mammogram facilities to ensure members with referrals complete their mammogram and conduct follow-up outreach to members if they miss their appointmentIdentify barriers and social determinants of health associated with mammogram completion Include ICD-10 Z codes forsocial determinants of health on claims submitted to BCBSIL so that we can help address barriers and connectmembers with available resources


1 American Cancer Society Cancer Facts amp Figures for African Americans 2019-2021 Retrieved Feb 10 2021 httpswwwcancerorgresearchcancer-facts-statisticshtml

2 CancerConnect Black American Women and Breast Cancer Disparity Sept 12 2020 httpsnewscancerconnectcombreast-cancerblack-american-women-and-breast-cancer-disparity-g082Ef4o7UqUGaGI1sSNzg

The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider Physicians and other healthcare providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatmentReferences to third party sources or organizations are not a representation warranty or endorsement of such organizations Any questions regarding those organizations should be addressedto them directly The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to theircertificate of coverage for more details including benefits limitations and exclusions Regardless of benefits the final decision about any service or treatment is between the member and theirhealth care provider

Bright Pink is an independent company that provides health information content for BCBSIL Bright Pink is solely responsible for the products and services that it provides



April 2021

Blood Pressure Control Speaking Out About the lsquoSilent Killerrsquo

High blood pressure or hypertension is known as a silent killer because it usually has no warning signs Nearly half ofadults in the US have hypertension according to the Centers for Disease Control and Prevention (CDC) and only about1 in 4 adults have the condition under control Encourage our members to talk with you about their blood pressure andheart health

Controlling high blood pressure can prevent heart disease and stroke which are among the leading causes of death in theUS According to the American Heart Association blood pressure control can also reduce the risk of kidney diseasevision loss peripheral artery disease and sexual dysfunction

Controlling high blood pressure is recognized as a quality measure by the National Committee for Quality Assurance(NCQA) The NCQA recommends controlling both the systolic blood pressure (SBP) and diastolic blood pressure (DBP) inadults as follows

SBP lt 140 mmHgDBP lt 90 mmHg

View our clinical practice guidelines on hypertension

Best practices include talking with our members aboutTaking medications as prescribedSmoking cessationIncreased physical activityMaintaining a healthy weightLimiting alcohol intakeEating a low-sodium dietReturning for follow-up visits

Please reach out to our members who cancel or miss appointments and assist them with rescheduling as soon aspossible Best practices also include using the proper codes when filing claims Proper coding can help identify gaps incare provide accurate data and streamline your administrative processes





Read More

Read More

Read More

Read More

Read More

BCBSIL offers free webinars and workshops for the independently contracted providers whowork with us A preview of upcoming training sessions is included in this monthrsquos issue

Clinical Updates Resources and RemindersWhen and How to Use Our Medical Policy Reference ListChecking eligibility and benefits confirms if prior authorization or pre-notification are requiredBut how do you know when to submit a voluntary predetermination request prior torendering services for our commercial non-HMO members Our Medical Policy ReferenceList can help

Reminder Hospital Administrative Days May Be Covered for Medicaid MembersBCBSIL will provide reimbursement for authorized inpatient stays extended beyond medicalnecessity also known as Administrative Days (ADs) for some BCCHP and MMAI members fordates of service on or after July 1 2019

Electronic OptionsSingle Online Access Point for EFT and ERA Enrollments Effective May 3 2021Starting May 3 2021 BCBSIL will offer a single access point for enrollment in ElectronicFunds Transfer (835 EFT) andor Electronic Remittance Advice (835 ERA) via the TransactionEnrollment tool on the Availityreg Provider Portal

Pharmacy ProgramSpecialty Pharmacy Update Changes to Select Medication List Effective June 12021Choosing a drug from our Select Medication List and billing for it with the appropriate NationalDrug Code (NDC) may result in a higher reimbursement rate than the rate applied for othernon-listed drugs in the same class

Read More

Read More

Read More

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Read More

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Quick Reminders






April 2021





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11 am to noon



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April 15 2021 1 to 2 pm




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Noon to 1 pm


April 14 2021 10 to 11 am


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April 21 2021 10 to 1130 am




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April 13 2021 10 to 11 am




April 2021












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April 2021






















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April 2021













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April 2021





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11 am to noon



11 to 1130 am


April 15 2021 1 to 2 pm




11 am to noon




April 15 2021 1 to 3 pm



Noon to 1 pm


April 14 2021 10 to 11 am


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April 21 2021 10 to 1130 am




Blue UniversitySM






April 13 2021 10 to 11 am




April 2021












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April 2021



















STC01-01 A3

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April 2021






















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April 2021





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11 am to noon



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April 15 2021 1 to 2 pm




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April 15 2021 1 to 3 pm



Noon to 1 pm


April 14 2021 10 to 11 am


April 20 2021 10 to 1130 am


April 21 2021 10 to 1130 am




Blue UniversitySM






April 13 2021 10 to 11 am




April 2021












April 2021























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April 2021













April 2021



















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April 2021






















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April 2021













April 2021





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April 14 2021 10 to 11 am


April 20 2021 10 to 1130 am


April 21 2021 10 to 1130 am




Blue UniversitySM






April 13 2021 10 to 11 am




April 2021












April 2021























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April 2021



















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April 2021
























April 2021














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11 am to noon



11 to 1130 am


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April 15 2021 1 to 3 pm



Noon to 1 pm


April 14 2021 10 to 11 am


April 20 2021 10 to 1130 am


April 21 2021 10 to 1130 am




Blue UniversitySM






April 13 2021 10 to 11 am




April 2021












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April 2021













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11 am to noon



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April 14 2021 10 to 11 am


April 20 2021 10 to 1130 am


April 21 2021 10 to 1130 am




Blue UniversitySM






April 13 2021 10 to 11 am




April 2021












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April 2021



















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April 2021
















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April 14 2021 10 to 11 am


April 20 2021 10 to 1130 am


April 21 2021 10 to 1130 am




Blue UniversitySM






April 13 2021 10 to 11 am




April 2021












April 2021























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STC01-02 562

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April 2021






















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April 2021













April 2021







11 am to noon



11 to 1130 am


April 15 2021 1 to 2 pm




11 am to noon




April 15 2021 1 to 3 pm



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April 14 2021 10 to 11 am


April 20 2021 10 to 1130 am


April 21 2021 10 to 1130 am




Blue UniversitySM






April 13 2021 10 to 11 am




April 2021












April 2021























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April 2021













April 2021



















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April 2021






















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women1













April 2021















11 am to noon




April 15 2021 1 to 3 pm



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April 14 2021 10 to 11 am


April 20 2021 10 to 1130 am


April 21 2021 10 to 1130 am




Blue UniversitySM






April 13 2021 10 to 11 am




April 2021












April 2021























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April 2021













April 2021



















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STC01-02 562

STC01-03 85






April 2021






















April 2021














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women1













April 2021


















April 13 2021 10 to 11 am




April 2021












April 2021























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STC01-03 85






April 2021






















April 2021














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April 2021













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April 2021






















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April 2021















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April 2021



















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April 2021































April 2021



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April 2021













April 2021























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April 2021



















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April 2021














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STC01-02 562

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STC01-01 A3

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STC01-03 85






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April 2021






















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April 2021













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April 2021













April 2021














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April 2021
















April 2021































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April 2021













April 2021































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April 2021



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April 2021























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April 2021













April 2021



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April 2021














